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Menopause and Premature Ovarian Insufficiency

NICE guideline [NG23] Menopause: identification and management. Last updated: Nov 2024. NICE CKS Menopause. Last revised: Apr 2025.

Background Information

Term Definition
Menopause Biological stage where menstruation stops permanently due to loss of ovarian follicular activity

Usually happens between 45-55 y/o, mean age of menopause is 51 y/o
Early menopause Menopause that happens between 40-45 y/o
Peri-menopause The period before menopause where there is irregular cycles of ovulation and menstruation
Post-menopause The period after menstruation have not occured for 12 consecutive months
Premature ovarian insufficiency (premature ovarian failure) Transient or permanent loss of ovarian function before 40 y/o

Menopause Guidelines

Clinical diagnosis (with no blood tests) of menopause if:
  • ≥45 y/o, AND
  • ≥12 months of amenorrhoea

For those with menopause associated symptoms <45 y/o → take 2 samples of serum FSH level to confirm the diagnosis:
  • 40-44 y/o + menopause + ↑ FSH: early menopause
  • <40 y/o + menopause + ↑ FSH: premature ovarian failure
 

Do not use FSH blood test to identify menopause in those using COCP or high-dose progestogen.

FSH levels can be unreliable in the presence of tamoxifen.

Do not offer all the below routinely to patients, treat accordingly to what the patient presents with.
 

  • 1st line: hormone replacement therapy (HRT)
  • 2nd line: menopause-specific CBT (in addition to HRT or alone with HRT not appropriate)
  • 3rd line: SSRIs / SNRIs / clonidine

  • 1st line: vaginal oestrogen +/- non-hormonal vaginal moisturisers / lubricants
  • 2nd line: non-hormonal vaginal moisturisers / lubricants alone 
  • 3rd line: vaginal prasterone
  • 4th line: oral ospemifene

 

Vaginal oestrogen should be avoided in those with a personal history of breast cancer → offer non-hormonal vaginal moisturisers / lubricants as 1st line

However NICE do state that vaginal oestrogen is likely to be safe in those with a personal history of oestrogen receptor -ve breast cancer.

Consider:

  • HRT
  • CBT

Consider menopause-specific CBT

Consider testosterone supplementation if HRT alone is not effective.

Premature Ovarian Insufficiency

Diagnose premature ovarian insufficiency if:
  • <40 y/o with menopause-associated symptoms, and
  • ↑ FSH levels on 2 blood samples taken 4-6 weeks apart

Offer sex steroid replacement in the form of HRT or COCP until 51 y/o (age of natural menopause)

References

Author: Adams Lau
Reviewer:
Last edited: 10/07/25